SSRIs Can Cause Rapid Cycling From Mania to Depression and Back in So-Called Bipolar Patients

Tuesday,May18th,2010

Paragraph four reads: "Although psychiatrists are in a big debate about this, the bulk of the evidence suggests that antidepressants can be double-edged swords in bipolar disorder. They can treat depression, but they seem to make some people have worse manic symptoms or begin to cycle rapidly between manias and depressions. You may well find that a medication such as lithium or valproic acid goes much further toward helping your symptoms. In some people, one of these medications is enough to provide emotional stability. In others, an antidepressant is also required to cope with depressive symptoms."

What can a bipolar person do to handle stress better?

Asked by Marshall Andrews, Bedford, Indiana

I was diagnosed with bipolar disorder when I was 16, and I'm now 18 and it has gotten where I can't even get a job because I stress myself out so much that I can't even think straight. I've been on Zoloft, Prozac, Lexapro, and Seroquel but nothing has helped me get over this. I feel like every time I try to do something a switch comes on in my head, and I get in fight-or-flight mode, and I usually flee. My sleeping patterns are also irregular. If anyone has some suggestions for me I would greatly appreciate it.

Expert answer

Dear Marshall, I am sorry to hear about your situation, and I've been thinking about it for a while and about the larger issue — that it is sometimes hard for me to make specific recommendations to questions sent in because psychiatric issues are almost always complicated, and readers' questions are, by necessity, short. In your case it seems to me that the essential question, which isn't altogether clear, is how much of your difficulty with job interviews comes from symptoms of your bipolar disorder versus being "psyched out" by the prospect of a job interview.

Not knowing the specifics, let's address each of these issues, starting with the bipolar disorder. I note from your list of medications that you have been on three antidepressants (Zoloft, Prozac and Lexapro) and on atypical antipsychotic (Seroquel). This leaves many medications that are known to be helpful in bipolar disorder untried, including lithium, valproic acid (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal) and a number of other atypical antipsychotics.

Although psychiatrists are in a big debate about this, the bulk of the evidence suggests that antidepressants can be double-edged swords in bipolar disorder. They can treat depression, but they seem to make some people have worse manic symptoms or begin to cycle rapidly between manias and depressions. You may well find that a medication such as lithium or valproic acid goes much further toward helping your symptoms. In some people, one of these medications is enough to provide emotional stability. In others, an antidepressant is also required to cope with depressive symptoms.

So the first thing I would recommend is talking with your clinician about trying one of these standard treatments for bipolar disorder. If you find significant relief, this in itself may make the search for a job far more bearable.

Although it is not quite explicit, I get a sense from your question that you have intense anxiety specifically related to the search for a job. Let me recommend a couple of approaches to this problem. My strongest recommendation would be to work with a behaviorally oriented psychotherapist around this issue. Dealing with what you rightly call the "fight-or-flight mode" by yourself can be overwhelming. A trained therapist could be hugely helpful in breaking down the problem into manageable pieces and working with you to overcome these one by one.

A second possibility would be to discuss use of an anxiolytic medication with your clinician when you are faced with specific activities that evoke so much anxiety that your ability to cope becomes compromised. While safe and often highly effective, these medications (called benzodiazepines) can be habit forming and so need to be approached with some care. Needless to say medication and therapy can, and probably often should be, combined.

I feel the need to add a postscript to my comments. Medications are the same whether you live in Klamath Falls or Kalamazoo, but finding a good therapist, let alone getting insurance coverage for him or her, varies widely from place to place and from individual to individual. I am not in a position to help my readers address or resolve these issues, unfortunately. In your case, there are a number of support groups and organizations that might serve as a resource for identifying opportunities in your area. Two websites of relevance include the National Alliance on Mental Illness and the Child & Adolescent Bipolar Foundation.